Posted by: Diana Cassar-Uhl, MPH, IBCLC | December 2, 2013

On mothers, mammograms, and moving on


It was a simple enough text message from my husband, who is holding down the fort at home in New York while I’m working in a public health fellowship in Washington, DC.

“Forgot to tell you, a nurse from Keller called. Said you are due for mammogram. Said you can call radiology directly to schedule.”

It makes perfect sense. I turned 40 in April and it’s December now, so the call shouldn’t come as a surprise. What is surprising, though, is that upon reading the text, I instantly fell apart and was consumed by my own sobs and tears. Why is there so much emotion wrapped up in the idea that it’s time for me to get a routine breast screening?

I think back to January of 2003, nearly 11 years ago. I was sitting on the exam table in the oh-so-flattering paper gown at my 6-week postpartum checkup with my OB/GYN at the Army hospital. My infant, who hardly slept the first three years of her life, snoozed in her car seat on the floor, allowing me to have a conversation with the doctor.

“There’s this lump here,” I showed her. “I think it’s a galactocele.” I wasn’t yet a lactation expert, but I had read up enough about breast abnormalities to realize that a bean-sized lump that only appeared in the same place when my breast filled between feedings was probably just a little pocket of milk. She agreed, then asked me, “how’s your mom doing?” I had learned a few weeks before my baby was born that my mother had breast cancer—estrogen receptor-positive cancer. It was detected early and hadn’t spread, but she had begun taking Tamoxifen, per the protocol for that kind of cancer.

She was also preparing to move 700 miles away from me the following week. I was a first-time mother with a baby who didn’t sleep; I was going back to a job I didn’t really miss in a month and I hadn’t yet found “suitable” childcare (who was going to replace me? I couldn’t fathom leaving my baby anywhere!); my mother, who lived 20 minutes away from me since I graduated from college over 7 years prior, was moving 700 miles away from me; and she had cancer.

Mom’s oncologist suggested I would want to get a baseline mammogram when I turned 30, less than 4 months ahead. “You’d have to quit breastfeeding to do that,” my doctor said, “but since breastfeeding is supposed to be protective for both you and your daughter, you might as well just get the mammogram whenever you wean naturally.”

I doubt anyone suspected that I’d be breastfeeding children continuously for the next decade—I know I didn’t. There was a study being conducted at the facility where I got my medical care; it was about the efficacy of bioelectric impedance imaging in early detection of breast cancer. The recruiting nurse, after a few years, finally stopped approaching me in the waiting rooms at my childrens’ well-child visits. Instead, she smiled and simply said “not weaned yet, right?” Around my 38th birthday, at my annual checkup, it was suggested to me that I get a mammogram—or even a simple ultrasound image—regardless of the fact that I was still lactating, because my mother was unsure but thought one of her doctors told her she was a carrier of a mutated BRCA gene. If she is (if I am), my risk for developing cancer is disproportionately high. I called around to facilities that should have had a radiologist on hand who could read an image of a lactating breast, but came up empty. In the midst of a career change and dealing with a major medical procedure for one of my children, I gave up trying to get either a baseline image of my breasts or a genetic test for the BRCA mutations. Neither was coming easily and I was tired.

Fast-forward a few more years. My youngest daughter has weaned, I believe. I would be more definite about saying so but, with her 6th birthday approaching this week, she’s still not admitting to having weaned. It’s been a good year and a half since I’ve had any milk, and her weaning has been so gradual that I’ve wondered for over a year whether each time she latched on was going to be her last. I thought she was all done this summer, but she nursed a few more times this fall after my week-day move to Washington. It was only 15 seconds on one side—definitely more for her peace of mind that she could nurse if she wanted to—but I struggled with whether I was still a breastfeeding mother.

The call to get my mammogram holds all of this within it. I’m 40 now; maybe the recommendations are antiquated and maybe the evidence isn’t really supportive of the practice but 40 year-old women get a mammogram. I can face my chronological age with confidence knowing that I’ve employed so many known protective factors over the last 20 or so years: regular exercise, healthy diet, and lots of breastfeeding; but my mother’s history nudges me to remember that sometimes, there isn’t a way to outrun risk.

What makes my heart the heaviest, though, is that, when I present myself for imaging of my breasts, I’m conceding—really, truly conceding that my breastfeeding days are over. I’m no longer lactating, I have no more reason to delay that baseline image. I’m in a new season as a mother, and it’s a wonderful, fun season of children who use toilets (mostly) by themselves, who can appreciate a nice meal at a decent restaurant and be pleasant company during it, who have interests and activities that I love participating in with them. I embrace that things are as they should be, but I can’t promise I won’t cry a little when I report for that mammogram—confronting my advancing age, a family history that’s a little bit scary, and the defining chapter of my life that is now undeniably closed.

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Responses

  1. Diana, this is a very moving story. You brought me to tears at least twice with this one. First, I remember not wanting to admit that my son had weaned. It took me several months after his last nursing to really see that it had happened.

    Second, I know we’ve had this discussion before about the BRCA gene and why certain people, like you, should be screened. I have already heard from my ob/gyn that when I turn 40 next year I need to schedule my first mammogram. But, what do you really think about the test? Do you think direct radiation on the breast has any lasting negative effects? I’ve been wondering how many false positives, how many suspicious lumps, lead to exploratory surgery when in fact there was nothing to worry about in the first place. What do you think about my feelings/fears about that? Anything you can tell me to make me feel better about this?

    • Hi Lisa,

      Thanks for reading. I’m glad to hear I wasn’t the only one in denial about being all done with breastfeeding! It has been truly the most defining experience of my life and to have it be really over is strange.

      With regard to the mammograms, I honestly don’t know. I haven’t reviewed the evidence either way closely enough to be able to say yea or nay definitively. I don’t think having one annually at our age (I’m already 40) makes a whole lot of sense, so I’m glad that recommendation has been adjusted. I do know that my mother wouldn’t have known at all that she had cancer had it not been for that mammogram she got sort of as an afterthought (she hadn’t gotten one in years, thought getting one while she still lived in NY would be a good move). I have smart friends who I respect who are 100% against mammograms and others who say they are vital. When I call radiology, I’m going to ask if there are other options (thermography, ultrasound) available to me, but I suspect there aren’t because I’m in the military system, which is of very inconsistent quality. I suppose if you are comfortable with doctors in your area, you can ask about alternatives and how those practitioners feel about their skill in using and assessing the results of those alternatives. There’s a lot to be said for lifestyle and risk but with the chance that I’m a carrier of a BRCA mutation (I’d love to know for sure but Tricare won’t send me for the test because I only have one 1st-degree relative with cancer … my mom is an only child, so I don’t have any aunts on her side!), I do think screening of some sort, starting now, is prudent.

      I know I haven’t given you much of an answer but if you do some research and asking around, please share whatever you learn and I’ll do the same.

  2. Dear Diana,
    what a moving blog post!
    As with most things you will make the decision what works best for you in terms of which procedure to use to get your baseline. I have looked into those things more for my mother than for myself since I am not of age yet ;-) and breastfeeding my 10 month old. I have however heard from friends that thermography is not as expensive as one may think. My friends and I are all military spouses so we talked about tricare probably not covering the cost if we decided thermography was the right choice for us.
    Maybe tricare will surprise and say yes….maybe one day they will cover my chiropractor bill…. Maybe not ;-)

    I wish you all the best and I hope you find what works for you.

    Sincerely Nina

  3. Hi Diana,

    What a wonderful post. Thank you for sharing your feelings from the weaning to the mammograms.

    I am not sure what I will offer will help. However, you may recall that my mother was diagnosed with breast cancer when we were in college. She was first diagnosed when when she was 49 and then again when she was 54, and at that point it spread to her liver and she was classified as terminal. Well, my mother is stubborn and found a doctor who would remove the cancerous portion of her liver, which at that time was unheard of. Thank goodness for her stubbornness and for that doctor as she has been cancer-free since the mid-1990s and is around today at the young age of 73. She has seen five grandbabies be born and grow up, with the youngest age 2 and the oldest almost 20.

    I was told to get a baseline at 32. Having not had any kids, I opted to do this. This lead to an ultrasound, which made me cry because I thought my first ultrasound would be seeing my unborn baby, but instead it was my left breast and the underarm. Since the ultrasound produced unclear results, the next step was a laser biopsy. This was successful and everything turned out fine. I continued to have mammograms until I turned 36. At that point I became pregnant with Mikayla and she nursed the best she could for 11 months. I was told to go for another mammogram four months after she weaned…well, I was pregnant with Sarah when that time came around. After Sarah weaned herself at nine months, I waited the four months again and returned to have my mammogram right before my 40th birthday. It came out fine and had one again this year, which was also thankfully fine.

    With my mother’s history, there was a peace of mind to get the baseline, even though for a few weeks after that first baseline, I was very scared because I thought that if there was a cancerous lump, this would alter or even stop my chances of having children. I am very thankful that it turned out well.

    Sorry for the long story. It does not answer your question. I am not sure if it helped, but I hope that it did in someway.

    xoxo,
    Amy

    • I do remember, Amy. I remember we were all very worried about her and I’m not the least bit surprised that you came from a stubborn fighter. :)

      I’m typically rather cavalier about medical procedures and governmental recommendations, because my own research so often tells me that the “evidence” is insufficient to recommend a course of action. With this, though, because there are unknowns and I do know I have a lot of suspected risk factors for the development of certain cancers (insulin resistance, I’m highly estrogenic), I’m willing to participate in screening. I’m not afraid at all. I’m probably going to do the mammogram this time around because I’m pressed for time and I want to “check the box,” but unless I realize additional risk factors (such as confirmation that I’m BRCA+), I won’t be looking for annual screening for some years yet.

  4. Hi! I’m trying to find someone local (Baltimore/DC area) who could accurately read the mammogram of a a good friend who is breastfeeding. Any recommendations on how I can find someone with that expertise and capability?

    • The best guidance I can offer is to call around to cancer centers and see if there are radiologists there who will read images of lactating breasts. Another option might be to see if there’s a local breastfeeding medicine specialist who can give a referral. Good luck!


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